Complex needs and overlapping vulnerabilities frequently reported by 'high-risk' gay men in Scotland

A quarter of Scottish gay men who are newly diagnosed with HIV or a rectal sexually transmitted infection (STI) report two or more vulnerabilities such as problematic alcohol use, low self esteem, mental health problems, social deprivation or experience of violence and childhood sexual abuse.

“The risks they are taking with their sexual health may be a symptom of these wider syndemic affects,” comment the researchers. “The diagnosis of a rectal STI (and particularly repeat diagnosis) should trigger an intensive package of HIV prevention support for the individual which must include an assessment for other overlapping vulnerabilities experienced.”

The analysis comes from a needs assessment conducted by NHS Lothian and NHS Greater Glasgow and Clyde, the health boards which cover Scotland’s two largest cities.

As part of the needs assessment, researchers conducted a case note review, examining the clinical records of men who have sex with men who were diagnosed with an infection suggestive of high-risk sexual behaviour. The review included 209 HIV-negative men who had rectal chlamydia or gonorrhoea, 78 men who were newly diagnosed with HIV, and 74 men who had been diagnosed with HIV for more than a year and were recently diagnosed with a rectal STI.

The aim was to have a better understanding of the men who have sex with men who are most at risk of acquiring or passing on HIV, so as to better design effective and targeted HIV prevention interventions.

These data were complemented by interviews with 20 sexual health clinicians and 154 men who have sex with men, as well as analysis of previously published surveys conducted in commercial gay venues in Scotland.

In terms of demographics, the men identified as being at increased risk mostly lived in urban areas, were white, only reported male partners and self-identified as gay.

In addition, the case note review identified a significant group of men reported a clustering of psycho-social and behavioural risk factors alongside their risky sexual behaviour. These factors included poor emotional wellbeing or a mental health concern that required professional help; problematic alcohol consumption; experience of physical, emotional or sexual abuse; living in an area of social deprivation; homelessness; joblessness or financial worries; and involvement in prostitution.

Men were considered ‘vulnerable’ if they reported two or more of these issues. This was the case for 24.4% of the HIV-negative men who had a rectal STI and 28.3% of those newly diagnosed with HIV. But it was especially common among HIV-positive men who had ongoing sexual risk behaviour – 50.0% of these men were considered to be vulnerable.

Difficulties with mental health were more common in men newly diagnosed with HIV (28.2%) and HIV-positive men who had an STI (36.5%) than in HIV-negative men with an STI (9.1%).

Poor emotional wellbeing (low mood, poor self-esteem, loneliness, etc) was recorded in the clinical notes of at least one-in-five men from all three groups. Men reported that this made it difficult for them to negotiate the safer sex they wanted, or that their desire for intimacy overrode their need to minimise HIV risks. Men reporting poor emotional wellbeing were more likely to be diagnosed with repeated rectal STIs, to report never using condoms for anal sex and to have infrequent engagement with specialist sexual health services.

Many men reported that drinking alcohol was linked to sexual risk taking, as it helped lower inhibitions, impaired ability to assess risks and negotiate sex, and sometimes led to memory loss about sexual encounters. A smaller number of men, and HIV-positive men in particular, attributed similar experiences to illegal drug use.

The authors of the needs assessment comment that current sexual health services and current HIV prevention interventions do not provide an adequate response to the problems of emotional wellbeing, mental health and alcohol use. Services should routinely assess these issues in men with sexual risk behaviour. They recommend that a tiered model of care is available in sexual health services, so that brief interventions can be provided before problems reach a crisis stage and referrals are available for individuals with greater needs. Men with multiple vulnerabilities would benefit from intensive one-to-one support which focuses on the overlapping issues which impact on sexual risk taking, they say.

The Scottish needs assessment has been published at the same time as Public Health England have drawn attention to the multiple health inequalities experienced by men who have sex with men – greater use of alcohol, drugs and tobacco; higher rates of depression, anxiety and suicidal thoughts; and poorer sexual health than the general population. These health inequalities frequently co-exist and influence each other, they say. “These health issues and inequalities are shaped by the wider socio-economic and cultural context in which MSM live,” comment Public Health England. “They include the experience of, or the fear of, stigma and discrimination across all areas of life – from schools to the workplace.”